Exact drug/PCI strategy depends on bleeding risk, renal function, planned invasive strategy, and local protocol.
1. Reperfusion STEMI
FMC-to-device ≤120 min; door-to-balloon ≤90 minFibrinolysis
If PCI delay >120 min, onset usually <12 h, no contraindicationAfter lysis
Transfer for rescue PCI if failed / routine early angiography
2. Antiplatelet therapy
Chewed loading dose unless contraindicatedP2Y12 inhibitor
Choose/timing with PCI vs conservative strategy in mindDAPT
Aspirin + P2Y12; individualize duration/bleeding risk
3. Anticoagulation
Common around PCIEnoxaparin
Renal function and age matterFondaparinux
NSTE-ACS option; not sole agent during PCI
4. Adjuncts + secondary prevention
Pain/BP relief; avoid RV infarct, hypotension, PDE-5 exposureβ-blocker
If no shock/HF/bradycardia riskHigh-intensity statin
Early unless contraindicatedO₂
Only if hypoxemic/respiratory distress
“Troponin decides STEMI” — nope.
STEMI is an ECG-driven reperfusion emergency. Draw troponin, but do not wait for it before activating reperfusion.
NSTEMI versus unstable angina
Both have ischemic symptoms without persistent ST elevation. NSTEMI has a rise/fall in cardiac troponin with at least one value above the assay’s 99th-percentile upper reference limit. Unstable angina has no biomarker evidence of necrosis; it is less common with high-sensitivity assays.
ST depression ≠ “safe.”
Dynamic ST-T changes, recurrent pain, instability, or high-risk troponin/risk profile push NSTE-ACS toward an early invasive strategy. Posterior MI can present with ST depression—use posterior leads when suspected.
Inferior MI: pause before nitrates.
Check for right-ventricular infarction (right-sided leads) and hypotension. Preload reduction can crash an RV-dependent patient.